Achilles Tendinopathy Exercises 2026 | DPM Guide

Protocol Phase	Weeks	Exercise	Load	Frequency	Progression Criteria
Phase 1 — Isometric (Pain Control)	1–2	Isometric calf hold: standing, rise onto ball of foot; hold 45 sec	70–80% bodyweight (sustained)	5 × 45 sec holds; daily	Pain ≤3/10 during exercise; morning stiffness <30 min
Phase 2 — Eccentric Loading (Core)	3–6	Alfredson eccentric heel drops: step edge; rise bilateral; lower single-leg over 3 sec	Bodyweight; add 5–10kg vest at week 5–6	3 × 15 reps; 2×/day; 7 days/week	Pain ≤5/10 during; pain resolves within 24h; no next-morning worsening
Phase 3 — Heavy Slow Resistance	6–10	Bilateral calf raises progressing to single-leg; add weighted vest or calf raise machine	6–8 RM (heavy); slow 3-sec concentric + 3-sec eccentric	3 × 6–8 reps; 3×/week	Single-leg calf raise strength within 90% of other side
Phase 4 — Energy Storage (Plyometric)	10–14	Double-leg then single-leg jump and land; rope skipping; bounding	Body weight; progressive impact	2–3×/week	Hop series >90% symmetry; no pain during or after
Phase 5 — Return to Sport	12–16+	Sport-specific running volume; field drills; cutting at speed	Full; managed by 10% weekly increase	Progressive; 3–5 sessions/week	VISA-A score >80; pain-free running for 2 weeks at target volume

Tendinopathy Location	Best Exercise Protocol	Exercises to Avoid	Adjunct Treatments	Surgery Threshold
Mid-Portion Achilles (2–6 cm above heel)	Alfredson eccentric heel drops (gold standard)	Stretching into end-range dorsiflexion; running on slopes	ESWT (shockwave), PRP; load management; custom heel lift orthotic	After 6 months conservative failure; consider debridement + tendon scraping
Insertional Achilles (at calcaneal attachment)	Modified eccentric — avoid full heel drop below step level (compresses insertion); use flat surface	Standard Alfredson drop below step; direct compression from shoe heel counter	ESWT most evidence-based; heel lift (reduces Achilles angle); consider Haglund’s resection	After 6 months; resection of Haglund’s deformity + calcification debridement

Achilles tendinopathy is one of the most common — and most mismanaged — running injuries we see at Balance Foot & Ankle. The standard advice patients receive is “rest and stretch,” which unfortunately is exactly what Achilles tendons don’t respond to. Tendons heal through mechanical loading, not through rest. Stretching a tendinopathic Achilles compresses the insertion and frequently worsens symptoms. The science on Achilles tendinopathy treatment has been clear for over 20 years: progressive heavy loading of the tendon is the treatment. This guide will walk you through exactly how to do it correctly, how to differentiate mid-portion from insertional tendinopathy (because the exercises are different), and what to avoid that keeps most people from recovering.

What Achilles Tendinopathy Actually Is

Achilles tendinopathy is a degenerative condition of the Achilles tendon — not primarily an inflammatory one. This distinction matters enormously for treatment. For decades, “Achilles tendinitis” implied inflammation, leading to anti-inflammatory treatments (NSAIDs, corticosteroids, rest) as the primary approach. Modern tendon biology research established that chronic Achilles tendinopathy involves disorganized collagen fibers, failed healing attempts, and neovascularization — not an acute inflammatory cascade. Treating tendinopathy with prolonged rest allows the disorganized collagen to persist without the mechanical stimulus needed to reorganize it. This is why rest “works” temporarily (pain decreases) but the pain returns immediately upon resuming activity.

Mid-Portion vs. Insertional Achilles Tendinopathy

This is the most clinically important distinction in Achilles exercise prescription — and it’s where most generic exercise programs fail. Mid-portion and insertional Achilles tendinopathy involve the same tendon but occur at different anatomical locations and respond to different exercises. Confusing them is one of the most common reasons patients don’t respond to treatment they read about online.

Why Eccentric Loading Works

Eccentric exercise means loading a muscle-tendon unit while it lengthens — the opposite of a concentric contraction (shortening under load). When you lower your heel below step level, the calf-Achilles complex is producing force while elongating. This specific mechanical stimulus has been shown to: stimulate collagen synthesis and reorganization in degenerated tendon tissue, reduce neovascularization (the abnormal blood vessel ingrowth associated with chronic tendinopathy), decrease the concentration of substance P and glutamate (pain mediators in tendinopathic tissue), and increase tendon stiffness over 12 weeks of training. The key mechanobiological principle is that tendons adapt to the loads they experience — give them the right load, and they rebuild. Give them no load (rest), and the disorganized tissue persists.

The Alfredson Protocol (The Gold Standard)

The Alfredson protocol was published in 1998 and remains the most replicated, highest-evidence exercise treatment for mid-portion Achilles tendinopathy. In the original trial, 15 patients with 6+ months of chronic mid-portion Achilles tendinopathy completed the protocol and all 15 returned to their pre-injury running level. The control group (waiting list) had zero improvements. Subsequent systematic reviews have confirmed 60–90% success rates depending on chronicity.

Heavy Slow Resistance Alternative

The Heavy Slow Resistance (HSR) protocol was developed as an alternative to the Alfredson eccentric protocol for patients who find the Alfredson too painful or impractical. Instead of eccentric-only loading, HSR uses full range-of-motion (both eccentric and concentric phases) calf raises with heavier loads and slower tempo. A 2015 RCT (Beyer et al.) found HSR and Alfredson produced equivalent outcomes at 12 weeks, with HSR showing better patient adherence due to lower initial pain.

Exercise Modifications for Insertional Tendinopathy

Insertional Achilles tendinopathy requires a fundamentally different exercise approach. The insertion is a compressive zone — the tendon wraps around the back of the heel bone and is compressed against it during dorsiflexion (toes pointed up). This means that any exercise that takes the foot into dorsiflexion (including lowering below step level in a heel drop) compresses the insertion against the bone and flares symptoms. The Alfredson protocol performed on a step is contraindicated for insertional tendinopathy.

Supporting Exercises That Accelerate Recovery

The Alfredson protocol addresses the Achilles tendon directly, but ignoring the contributing factors — hip weakness, ankle dorsiflexion restriction, calf tightness proximal to the problem area — leaves recovery incomplete. These supporting exercises, performed 3× weekly alongside the main protocol, address the full injury picture.

Pain Monitoring During Exercises

Pain monitoring is critical to safe tendon loading. Unlike most musculoskeletal conditions where “no pain, no gain” is wrong, Achilles tendinopathy rehabilitation uses a specific pain-monitoring framework that guides when to load more, hold steady, or back off.

Products That Support Recovery

Red Flags — Stop Exercising and Seek Care

The Most Common Exercise Mistake

The most common mistake in Achilles tendinopathy rehabilitation is stopping the eccentric protocol as soon as pain improves — typically at 3–4 weeks — before the tendon has completed its structural remodeling. Pain reduction is not the treatment endpoint; 12 weeks of progressive loading is the treatment endpoint. Tendons remodel on a schedule driven by biology, not symptoms. Pain often decreases significantly by weeks 3–6 as the initial sensitization resolves, but the collagen reorganization required for mechanical durability continues through weeks 8–12. Patients who stop at “pain-free” and immediately resume full training volumes frequently re-injure within 4–8 weeks because the tendon is structurally improved but not yet maximally stiffened and reorganized. Complete the 12-week program even if symptoms resolve early.

Frequently Asked Questions

How long does Achilles tendinopathy take to heal with exercises?

The Alfredson protocol takes 12 weeks to complete, and most patients see significant improvement by weeks 6–8. Some patients with chronic tendinopathy (symptoms for 1+ years) may need 16–24 weeks. Acute tendinopathy (symptoms less than 3 months) typically responds faster. The key is patience — tendon biology has a fixed timeline that exercises can optimize but not rush. Completing the full 12-week program even after becoming pain-free is essential for preventing recurrence.

Can I run while doing Achilles tendinopathy exercises?

Yes, with appropriate pain monitoring. Running is not absolutely contraindicated during Achilles tendinopathy rehabilitation, but it should be managed: run on soft surfaces (grass, trails) rather than concrete, limit initial sessions to 20–30 minutes at easy pace, use the traffic-light pain framework to guide load decisions, and do not run on the same day as your eccentric protocol sessions in the first 4 weeks. Continuing some running maintains cardiovascular fitness and psychological wellbeing — both important to recovery compliance.

Should I stretch my Achilles tendon when it hurts?

For mid-portion tendinopathy: gentle soleus (bent-knee) stretching is acceptable. For insertional tendinopathy: avoid aggressive calf stretching entirely — it compresses the tendon against the heel bone at the insertion and directly worsens symptoms. Foam rolling of the calf (not the tendon itself) is fine for both types. The Alfredson eccentric exercises provide far more therapeutic benefit than static stretching for either form of tendinopathy.

What is shockwave therapy for Achilles tendinopathy?

Extracorporeal shockwave therapy (ESWT) delivers acoustic pressure waves to the tendon, stimulating tissue remodeling and reducing neovascularization. We use it at Balance Foot & Ankle for patients who’ve completed 6–8 weeks of the eccentric protocol without adequate improvement. The evidence for ESWT + eccentric exercises combined is stronger than either alone for chronic cases. Treatment typically involves 3–5 sessions, and results continue improving for 12 weeks after the final session.

The Bottom Line

Achilles tendinopathy responds to load, not rest. The Alfredson eccentric heel drop protocol — performed twice daily, 3 × 15 reps, into pain at ≤5/10 — produces 60–90% resolution rates over 12 weeks in mid-portion tendinopathy. Insertional tendinopathy requires the same eccentric loading concept but restricted to flat ground only, without any below-neutral heel lowering. The single most important factor in recovery is completing the full 12-week program consistently, even when symptoms improve early. If you’ve been doing eccentric exercises correctly for 8 weeks without meaningful improvement, come see us — shockwave therapy, platelet-rich plasma, and advanced imaging can identify and address what exercises alone can’t fix.

Sources

1. Alfredson H, Pietilä T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998;26(3):360–366.
2. Beyer R, Kongsgaard M, Hougs Kjær B, Øhlenschlæger T, Kjær M, Magnusson SP. Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy. Am J Sports Med. 2015;43(7):1704–1711.
3. Mafi N, Lorentzon R, Alfredson H. Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study. Knee Surg Sports Traumatol Arthrosc. 2001;9(1):42–47.
4. Magnussen RA, Dunn WR, Thomson AB. Nonoperative treatment of midportion Achilles tendinopathy: a systematic review. Clin J Sport Med. 2009;19(1):54–64.
5. Zwiers R, Wiegerinck JI, van Dijk CN. Treatment of midportion Achilles tendinopathy: an evidence-based overview. Knee Surg Sports Traumatol Arthrosc. 2016;24(7):2103–2111.

In-Office Treatment at Balance Foot & Ankle

If home treatment isn’t providing relief for your Achilles tendinopathy, our podiatry team at Balance Foot & Ankle can help with same-day evaluations and advanced in-office care.